Journal of Health Sciences 2012, 2(4): 29-32

DOI: 10.5923/j.health.20120204.02

Physical therapy management of Anterior Canal Benign

Paroxysmal Positional Vertigo by the Deep Head Hanging
Maneuver
Amer A. Al Saif1,* , Samira Alsenany2

1
Department of Physical Therapy, Faculty of Applied M edical Science, King Abdulaziz University, Jeddah, Saudi Arabia
2
Faculty of Applied M edical science, King Abdulaziz University, Jeddah, Saudi Arabia
aalsaif@kau.edu.sa

Abstract One important factor that can cause of dizziness is benign paro xys mal positional vertigo (BPPV); this increases
in prevalence with age. The aim of this clinical study was to determine whether the Deep Head Hanging maneuver is an
efficacious treatment maneuver for anterior canalithiasis. Twenty-eight adult participants were recruited. Their ages ranged
fro m 41–63 years. Thrteen participants were male, and fifteen were female. Part icipants were judged to be “clear” of the
anterior canalithiasis when there was no nystagmus or subjective vertigo elicited by diagnostic positioning at the follow-up
appointment. Results indicate that 82.1 % of the twenty-eight participants were clear o f anterior canalith iasis after one
treatment session, with another 14.2 % clear after a second treatment session. The remain ing 3.5 % required a third treatment
session. In Conclusion, the Deep Head Hanging maneuver was demonstrated to be a useful treat ment in patients presenting
with possible anterior canalithiasis sessions.
Keywords Dizziness, Canalithiasis, Benign Paro xysmal Positional Vertigo , Deep Head Hanging maneuver, Vert igo

that the presence of a spinning sensation and the absence of

1. Introduction
One important factor that can cause of dizziness is benign
paroxys mal positional vertigo (BPPV); this increases in
prevalence with age. Significantly, a study that compared
patients with BPPV referred init ially to a Falls and Syncope
Unit (FSS group) found that FSS patients were more likely to
have more than one type of dizziness (16% vs. 0%, p =
0.001), more likely to have cerebrovascular or
cardiovascular co-morbidity (13% vs. 4%, p = 0.0152) and
were taking significantly mo re medication (3.2 vs. 1.7; p = 0)
and that these issues could be a curable cause for dizziness
and so of falls in o lder people1).
Si milar ly , an ot her stu dy to d ifferent iat e bet ween
dizzin ess and balance d isorders used a cross-sect ional
design to verify the occurrence of unrecognized benign
paro xys mal pos it io nal vert igo (BPPV) and associat ed
lifestyle issues in a public, inner-city geriatric population.
The study noted that dizziness was co mmon in 61% of
patients, whereas balance disorders were found in 77% of
patients. In add it ion, n ine percent were found to have
unrecognized BPPV. Mu lt ivariate analysis demonstrated
* Corresponding author:
dr_amer112@hotmail.com (Amer A. Al Saif)
Published online at http://journal.sapub.org/health
Copyright © 2012 Scientific & Academic Publishing. All Rights Reserved
a lightheadedness sensation predicted the presence of
unrecognized BPPV. Patients with unrecognized BPPV
were more likely to have reduced activities of daily living
scores, to have had continual falls in the prev ious three
months, and to have depression. These data indicate that
unrecognized BPPV is co mmon among older people and is
related to causes of death 2). Significantly, many older
people with dizziness complain of two diverse types of dizzy
symptoms 3). The most common is a gait d isorder, but they
may also have symptoms stemming fro m the cardiovascular
and peripheral vestibular systems. Furthermore, some causes
of dizziness represent a danger to life. Similarly, another
study found that occurrence of BPPV increases with age.
Older people suffering fro m dizziness may be transferred to
a different special unit . Usually, the diagnosis of posterior
canal BPPV is expected when typical signs (nystagmus) and
symptoms (vertigo and nausea) are aggravated by positional
tests such as the Dix-Hallp ike test1).
Benign paro xys mal positional vertigo (BPPV) is the most
common otologic cause of dizziness 4,5). It is caused by
abnormal mechanical stimu lation of one or more of the three
semicircu lar canals (SCC) of the inner ear. W ithin the
labyrinth of the inner ear lie collections of calciu m crystals
known as otoconia2). For a variety of reasons, in patients with
BPPV, the otoconia are dislodged from their usual position
within the utricle and travel through the endolymphatic flu id
30 Amer A. Al Saif et al.: Physical therapy management of Anterior Canal Benign Paroxysmal
Positional Vertigo by the Deep Head Hanging M aneuver
into one of (SCC)5) .The presence of the otoconia in one of
the three semicircular canals causes the involved
semicircu lar canal to become sensitive to changes in
orientation of the head in the plane of the canal. It has been
reported that 80-95% of all BPPV cases are the result of
otoconia being trapped in the posterior SCC (PSC) and
10-12% in the horizontal SCC (HSC)4,5). There is much mo re
debate concerning the anterior SCC (ASC) and reports vary
fro m 2-21% of cases6) . Symptoms of BPPV include brief
attacks of dizziness or vertigo associated with nystagmus,
blurred vision, lightheadedness, loss of balance and nausea
that are triggered by angular position changes such as
bending forward, sitting up, and ro lling over in bed 2) . The
symptoms can last for days, weeks, or months, or be
recurrent over many years. In around half of BPPV cases, no
cause can be found (idiopathic BPPV). However, in older
people, the most common cause is degeneration of the
gelatinous mat rix within the utricle supporting theotoconia2
,7)
. The diagnosis of BPPV is relat ively straightforward due
to the characteristic history and positional vertigo, that can
be induced using the Hallpike-Dix maneuver2). The addition
of using infrared goggles with the Hallp ike-Dix maneuver
improves the accuracy of the test. During the Hallpike-Dix
maneuver, the patient long-sits on an examination table with
their head rotated approximately 45 degrees to one side. The
clin ician then assists the patient into a supine position with
their head and neck extended slightly belo w the level of the
table wh ile maintaining the rotated head position 2,8,9) . The
symptoms typically begin a few seconds after assuming this
position. This is due to the gravitational impact of the test
Position 1
Position 3
Figure 1. Deep Head Hanging Maneuver (Positions 1-4)
position which moves the otoconia within the SCCs. This
increases the internal pull on the endoly mphatic flu id of the
SCC, producing a mo re v igorous bending of the cilia within
the ampulla of the SCC2) . The end result of the Hallpike-Dix
test, in the presence of BPPV, is vertical-torsional jerk
nystagmus of typically short duration, suggesting a specific
type of BPPV called canalithiasis. In this research study, we
have operationally defined BPPV as the canalithiasis form.
The clinician can determine the SCC involved by analyzing
the eye movements provoked and the latency of nystagmus2).
ASC BPPV is characterized by paro xys mal down-beating
nystagmus lasting less than 60 seconds 10,11). The most
common clinical intervention for canalithiasis of the ASC is
the canalith-repositioning maneuver (CRM). However,
recent literature suggests using the (DH maneuver), as
illustrated by Yacovino et al, as the primary treat ment for
ASC BPPV13). The DH maneuver is performed on an
examination table in a similar manner to the CRM. Because
the ASC has a d ifferent trajectory fro m the PSC, maneuvers
targeting ASC BPPV differ geo metrically fro m those
described by Epley for PSC BPPV10). The idea of the DH
maneuver is to invert the ASC to allow debris to fall to the
"top" of the ASC, and then, upon returning the patient to the
sitting position, allow it to migrate into the common crus and
then the utricle10). The purpose of the current investigation
was to determine whether the DH maneuver is an efficacious
treatment maneuver for ASC-BPPV.
2. Methods
Position 2
Position 4
 Journal of Health Sciences 2012, 2(4): 29-32
Figure 2. Percentage of patients cleared of AC BPPC over the number of treatment sessions
All twenty-eight adult participants were recruited fro m
patients seen at King Abdulaziz University Hospital.
Informed consent was acquired prior to the beginning of the
study. Age ranged fro m 41–63 years with an average age of
55 years. Thirteen participants were male, and fifteen were
female. A C BPPV was confirmed in all participants with
Video-Nystagmography recording (VNG) after it was
determined that there was no central-mediated problem.
Participants were treated with the DH maneuver as
illustrated by Yacovino et al16). This consisted of four steps
with intervals of at least thirty seconds (Figure 1). In
Yacovino et al.’s method the the patient was first assisted
fro m a sitting position into a supine position with their head
extended backwards by 30°. This position is maintained
while their head is flexed forward 45°. Finally, the patient is
returned to the sitting position. In position 1, the otoconia lie
near the ASC ampulla .In position 2 (head-hanging position),
both ASC’s are inverted with their ampu llas superior and
their non-ampullary endings medial and inferior. Otoconia
migrate due to their weight towards the apex of the ASC. In
position 3 (chin to chest), g ravity facilitates further migration
towards the common crus. Finally, in position 4, the patient
sits up with head tucked in. Th is last step allows otoconia to
move through the common crus and into the utricle. The
author, who is experienced in the treat ment of ASC-BPPV
using the DH maneuver, conducted all treat ment sessions.
All participants received one DH maneuver treat ment per
appointment and returned for follow-up evaluation at
one-week intervals. Participants were judged to be “clear” of
the ASC-BPPV when there was no nystagmus or subjective
vertigo elicited by diagnostic positioning at the follo w-up
appointment.
31
3. Results
Participants included in the study were telephoned one
month following in itial clearance by the DH maneuver and
all reported 100% resolution of all symptoms.. As shown in
Figure 2, 82.1 % of the twenty-eight participants were clear
of AC-BPPV after one DH treat ment session, with another
14.2 % clear after a second treatment session. The remaining
3.5 % required a third treatment session. All participants
were cleared with in three treat ment sessions.
4. Discussion and Conclusions
The mechanis m driving BPPV is otoconia pathologically
located in one of the three SCCs of the inner ear. Because
otoconia have mass, angular position changes affect the
involved SCC as the otoconia move within the
endolymphatic flu id 2). This movement results in an increased
neural firing rate of the involved inner ear and a sensory
mis match between the systems responsible for position
-sense and balance2,15). The symptomatic consequences
include nausea and vertigo lasting fro m seconds to
minutes 1,2). Medical management aimed at resolving BPPV
includes the CRM and/or liberatory maneuvers depending
upon the specific BPPV type1,2). The purpose of the current
investigation was to determine whether the DH maneuver
wasis an efficacious treatment maneuver for AC-BPPV.
Results fro m the current study indicate that the DH
maneuver is successful in clearing AC-BPPV. The purpose
of the DH was to remove physically the otoconia from the
SCC and relocate them back into the utricle using gravity
and a systematic progression of head position changes4, 10.
32 Amer A. Al Saif et al.: Physical therapy management of Anterior Canal Benign Paroxysmal
Positional Vertigo by the Deep Head Hanging M aneuver
Approximately 96% of patients were clear within one or two
treatments. one study reported that all cases showed
excellent therapeutic response to the DH maneuver16).
Another study reported that vertigo and nystagmus in 29
patients fully resolved using this maneuver, 96.7% of
patients became sympto m free17). Based on these findings
and our results, and DH maneuver could be one of the most
effective treat ment methods for ASC BPPV. This compares
well with data reported in previous studies of treat ment
maneuvers for AC-BPPV using the DH maneuver as the
primary treat ment for A SC BPPV. The DH maneuver has the
advantage that the clinician does not need to know the
affected side13). The ASC is much nearer to the sagittal plane
than the PSC, so keeping the head in a neutral non-rotated
position is more beneficial in mob ilizing the particles in the
ASC co mpared to rotatory movements 13). There are t wo
major limitations in this study: the lack of a control group
and the difficulty in recruiting patients with ASC-BPPV
because it is a rare condition. Based upon the results of the
current study, the DH maneuver was demonstrated to be a
useful treatment in patients presenting with possible ASC
BPPV. Moreover, the results from the current study indicate
that approximately 96% of the participants were clear after
one or two DH maneuvers.
REFERENCES
[1] .Angeli.S, Hawley.S, Gomez.O : Systematic approach to
benign paroxysmal positional vertigo in the elderly",
Otolaryngol Head Neck Surg,vol. 2003. 128, pp.719-25.
[2] Baloh R. : Dizziness in older people", J Am Geriatr Soc,
1992.vol.40, pp.713–21
[3] Agrawal.Y , Carey.J, Santina.C, et al.,: Disorders of balance
and vestibular function in US adults: data from the National
Health and Nutrition Examination Survey 2001-2004". Arch
Int M ed. 2009. vol.169, no.9, pp.38-44.
[4] Bronstein AM Vestibular reflexes and positional manoeuvres.
J NeurolNeurosurg Psychiatry, 2003, 74:289–293. doi:
10.1136/jnnp.74.3.289
[5] Eric G. Johnson, Clinical M anagement of a Patient with
Chronic Recurrent Vertigo Following a M ild Traumatic Brain
Injury,” Case Reports in M edicine, 2009 .doi:10.1155/2009/
910596
[6] S. J. Herdman and R. J. Tusa, “Physical therapy management
of benign positional vertigo,” in Vestibular Rehabilitation,
2007, S. J. Herdman, Ed., pp. 233–260, F. A. Davis,
Philadelphia, Pa, USA, 3rd edition,.
[7] Jackson L, M organ B, Fletcher J, et al.: Anterior canal benign
paroxysmal vertigo: an underappreciated entity. OtolNeurotol,
2007, 28:218-222
[8] Parnes LS, A grawal SK, Atlas J :Diagnosis and management
of benign paroxysmal positional vertigo (BPPV), 2003,
CMAJ 169:681–693
[9] Korres S, Balatsouras DG, Kaberos A, et al.: Occurrence of
semicircular canal involvement in benign paroxysmal
positional vertigo. OtolNeurotol ,2002, 23:926-932.
[10] Parnes LS, M cClure JA: Free-floating endolymph particles: a
new operative finding during posterior semicircular canal
occlusion. Laryngoscope, 1992,102:988-992.
[11] FurmanJM , CassSP: Benign paroxysmal positional
vertigo. N Engl J M ed,1999, 341:1 590–1596. doi:10.1056/N
EJM 199911183412107
[12] EpleyJM : Human experience with canalith repositioning
maneuvers. Ann N Y ,2001, AcadSci 942:179–19.
[13] Kim YK, Shin JE, Chung JW. The effect of canalith
repositioning for anterior semicircular canal canalithiasis.
ORL J OtorhinolaryngolRelatSpec ,2005,67(1):56-60.
[14] Augusto P C, Niccolò C, Iacopo D, et al.: Anterior Canal
Lithiasis: Diagnosis and Treatment. Otolaryngology - Head
and Neck Surgery, 2012, 144 (3): 412-8.
[15] Epley JM : The canalith repositioning procedure: For
treatment of benign paroxysmal positional vertigo.
Otolaryngol Head Neck Surg ,1992, 107(3):399-404.
[16] Yacovino DA, Hain TC, Gualtieri F : New therapeutic
maneuver for anterior canal benign paroxysmal positional
vertigo. J Neurol ,2009, 18.
[17] Bertholon P, Bronstein AM , Davies RA, et al.: Positional
down beating nystagmus in 50 patients: cerebellar disorders
and possible anterior semicircular canalithiasis.
J Neurol Neurosurg Psychiatry,2002, 72:366–372. doi:10.11
36/jnnp.72.3.366
[18] AlSaif A, Johnson E: Cervicogenic Dizziness: Implications
for Physical Therapy. Indian Journal of Physiotherapy and
Occupational Therapy,2011, 5:6-11.